The ENN interviewed three members of the newly formed World Vision (WV) 'Nutrition Centre of Expertise (NCOE)' for this issue's agency profile slot. Carolyn MacDonald, Nutrition Director, along with Sarah Carr and Colleen Emary, both Nutrition technical specialists, all participated in the teleconference.

The NCOE was set up in January 2008 with a mandate to provide nutrition expertise for WV International (WVI) and to lead the organisation efforts towards higher quality programming in nutrition. The NCOE came about through the work of WV Canada, primarily a fund-raising and programme support branch of WV, which had begun to focus on providing technical assistance in the areas of nutrition, food security and health. Through various sources of funding (including the Canadian International Development Agency - CIDA), WV Canada had managed to build up a cadre of technical staff who were beginning to provide technical support for the wider organisation. The NCOE was able to build upon this technical group and therefore geographically locate NCOE in WV Canada. Unlike the WV Canada structure, where the Nutrition, Health and Food security supports all sit on one team and HIV/AIDS in another, the NCOE is located within the WVI Global Health and HIV/AIDS Team.

Another factor which contributed to the development of the NCOE was the realisation that rates of malnutrition were still worryingly high in WV programme areas - identified through the use of what WV calls 'transformational development indicators', including nutrition. In addition, WVI was undergoing a review at the time and was implementing structural changes within the organisation to improve efficiencies and effectiveness.

Domasi Fortification Unit in Malawi, supported by World Vision

The main NCOE activities are strategy development, capacity building (including around community-based management of acute malnutrition (CMAM) in emergencies), providing evidence based guidance for programming, leadership in operational research, leading a network of nutrition practitioners, networking externally, and advocating for improved nutrition policy and programmes (mainly internal). The NCOE is led by the Nutrition Director and NCOE Team Lead from the Global Health Team. There are 4.5 additional positions including emergency nutrition, research and evaluation (unfilled), project support/knowledge management, capacity building and tool and guidelines development. Funding for the NCOE comes from within WV and is relatively secure for the next two years.

Carolyn and Colleen identified a number of key NCOE achievements. The NCOE has developed a WVI nutrition framework governing WV's approach to addressing malnutrition, and nutrition is now explicitly integrated into the WVI 'Global Health and Nutrition Start Up Strategy'. The strategy focuses on promoting evidence-based interventions for pregnant women and children younger than two years, aimed at reducing maternal and child mortality, anaemia in women and children, and stunting in children. There have also been notable achievements with respect to capacity development. In 2006 WVI signed an agreement with VALID International to build capacity of field staff implementing CMAM - largely in emergencies. Work started initially in Ethiopia, south Sudan and Niger and involved extensive training of national staff. The programme has now expanded to 11 countries (all in Africa, except for Haiti) where there is now a trained cadre of local staff most of whom work with or through the Ministry of Health.The NCOE has also worked to build local capacity in development programmes focussing on behaviour change communication (BCC) and monitoring and evaluation in Asian programmes and Positive Deviance/Hearth in Latin American and Caribbean programmes. Capacity building of regional and national staff is seen as key to WVI success given the 'independence' and self-reliance of national offices. The challenge is to get good and consistent quality in programmes across the regions.

The NCOE has advocated for inclusion of nutrition in health policies and programmes. As a result, the WVI 5-year 'Global Child Health Campaign' has child nutrition as one of its three pillars. Two other important NCOE activities include the preparation of an on-line resource, the "Nutrition MarketPlace, Profiling World Vision's Best Practices in Nutrition" targeted to advocacy and programme audiences; and inclusion of nutrition within the minimum set of indicators in the new sponsorship minimum programme standards.

Achievements of the Centre are being closely monitored - there was an external evaluation after 6 months involving a number of stakeholders and an 18 month review has just been completed.

In spite of all the achievements of the NCOE, certain ambitions have yet to be realised. For example, the challenge remains to integrate nutrition into WVI agriculture, food security and livelihoods work. This is partly related to the lack of a clear WVI Agricultural Director and team, as well as a reflection of the work load of the NCOE, lack of staff time, the 'location' of NCOE separate to agriculture, food security and food aid technical supports, and the health and HIV/AIDS focus of the WVI Global Health Team. Some of the research activities have not materialised, while the anticipated level of programme support for monitoring and evaluation has not been achieved. Training achievements have also been disappointing. While many staff have been trained in CMAM, job commitments have meant that these trained staff have been unable to train others in neighbouring countries. As a result, the approach to staff capacity building has been modified.

An infant attending a
World Vision supported
outpatient therapeutic
programme in Kenya

The NCOE is currently interested in a number of research areas. These include infant and young child feeding, scale-up in the use of Sprinkles and other products to enhance micronutrient intake and status - for example, work on anaemia and vitamin D deficiency is ongoing in Mongolia. In addition, the NCOE is exploring the scaling up of small scale and medium scale fortification (building on work in Malawi and Tanzania) to increases micronutrient accessibility for WV beneficiary populations, including complementary foods for young children, as most WV beneficiaries cannot access centrally fortified foods. On the emergency side, the NCOE is looking at the use of mid-upper arm circumference (MUAC) as the exit criterion for feeding programmes.

Capacity building is an area that NCOE hopes to focus on even more in the future. This will include development of nutrition toolkits, face to face short workshops, mentoring, distance learning and strengthening WVI's virtual network to help share ideas and build competencies.

Colleen and Carolyn identified two major challenges affecting nutrition overall. The first is a gap between translating guidelines into programming. What is missing is the 'how' to implement evidence-based interventions. Guidelines are not sufficiently practical nor are they adequately contextually adaptable, whether for BCC activities or CMAM. Underlying reasons for malnutrition, including cultural practices, are varied and complex, and therefore require significant analysis and local contextualization for strong programme designs. A second and related challenge is the weak capacity and commitment of resources to scale up integrated nutrition programmes. There is little guidance on 'how' to scale up integrated, multiple-sector programmes, particularly given the marginalisation of nutrition within Ministries of Health or Agriculture, lack of resources for training and supervision and an overall lack of recognition of the importance of nutrition within government. What is so often lacking is coordination between the various sectors and an absence of critical analysis at national level. As Carolyn pointed out, "unlike HIV/AIDS, malnutrition is not an 'easy sell' unless children are already starving and near death - it is 'invisible', complex and very often a 'silent' issue".

In returning to the theme of how the NCOE came about and the likelihood of similar initiatives being launched by other agencies, Carolyn and Colleen both felt the trigger was a critical mass or core group of nutritionists who came to be valued by the wider organisation. The fact that the nutritionists were all within one location in WV Canada and not isolated was instrumental. The flexibility of the WV Canada nutritionists to network with global partners and with other sectors within the WV partnership was fundamental to the good results in nutrition. What is clear is that the NCOE has helped raise the profile of nutrition within the wider organisation and opened the door to more coordinated programming with other sectors.